Biologic Esthetic Restorations Jose' Fortunato Ferreira Santos, D.D.S.,* and Joel Bianchi, D.D.S!
Cases of serious coronal destruction were treated by bonding parts of extracted teeth to the coronal remnants by means of adhesives and photo-activated composite resins. The long-term clinical results have revealed very satisfactory clinical performance of the compounded restorations. No detrimental effects have been identified.
fter 6 years of research an innovative technique has been developed at the ClinicalResearch Center, Department of Dental Materials, University of SZio Paulo, utilizing the adhesive capabilities of new materials in combination with parts of extracted human teeth. Recently, improved adhesive materials have permitted the use of newly developed procedures for coronal restoration. A little more than a decade ago, Simonsen' described bonding fractured incisal edges to the remaining portion of crowns and emphasized two major advantages of such a practice: esthetics and wear resistance. At that time, bonding of dehydrated portions of teeth was not considered because of potential brittleness. In 1989 Santos and Cols2proposedreinforcement of posterior composite restoration with human enamel inserts. A series of well-documented cases have shown that such brittleness has not been clinically ~ b s e r v e d . It ~.~ seems that there is a critical period of 1 or 2 weeks after bonding, when rehydration of the bonded fragment is completed. In addition to the advantages mentioned by Simonsen' our experience has shown that bonding fragments of extracted teeth for coronal reconstruction has brought several more benefits such as (1) more conservative cavity preparation and less destruction of sound dental tissue, (2) a more natural esthetic result, (3)lower cost, and (4) more options for the d e n t i ~ t . ~ . ~ Representative cases of reconstructions by means of bonded fragments of extracted human teeth are presented to illustrate our new technique.
A
'Professor and Chairman:t Assistant Professor; Department of Dental Materials. Clinical Research Center. Untvemity of S o Paulo. Faculty of Odontology. S o Paulo. Brazil Address reprint requests to Professor Jose Fortunato Ferreira Santos. Clinical Research Center, University of S o Paulo. Faculty of Odontology. Av. Prof. Lineu Prestcs 2227. CEP 05508. S o Paulo. Brazil 0 1992 Decker Periodicals Inc.
MATERIALS Photo-activated composite resins associated with dentin and enamel adhesives, glass-ionomer cements, and parts of extracted human teeth were used for fabricating the restorations. The extracted teeth were thoroughly cleaned after the pulpal tissue had been removed through the apex, and stored in an antiseptic solution (70%ethanol). Just before bonding they were sterilized by humid heat (120" C) for 15 minutes.
TECHNIQUE Case 1 A young patient, 9 years old, had his left central incisor fractured in a swimming pool accident 4 days before coming to the office. At the initial appointment a clean-up was performed with a pumice/water slurry and an impression was taken (Fig. 1). A similar extracted tooth was selected and adjusted on the stone cast (Fig. 2).
Figure 1. Preoperative appearance of upper central left incisor, accidentally fractured.
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JOURNAL OF ESTHETIC DENTISTRY VOLUME 4. SUPPLEMENT 1992
Figure 2. Fragment of an extracted similar tooth adjusted on the stone cast.
Figure 5. Acid etchingof the semicircularbevel all around the bonding line.
Figure 9. Bonding of the selected fragment to the coronal
Figure 6. Postoperative facial view.
remnant of tooth 2 1.
Figure 4. Semiclrcular bevel being cut with a round diamond bur.
Figure 7. Preoperative view of fractured tooth 2 1.
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Biologic Esthetic Restorations
Figure 8. Checking interproximal contacts at the 4-year recall.
Figure 10. Appearance of tooth 37 at the 3-year recall.
situation where the entire occlusal table of a lower molar was restored with an adjusted tooth fragment, adhesive, and composite resin.
DISCUSSION Performance of the bonded restorations compoundedwith extracted human teeth, dentin and enamel adhesives, and composite resins have shown neither failures nor undesirable reactions during the 6-year recall period.3Conventional restorative dentistry might have been less effective due to its natural inherent limitations. Apart from the advantages already described, bonding human extracted teeth to coronal remnants offers better sealing and minimization of microleakage around the restoration, better long-term esthetic results, and more options for difficult clinical situations.
Figure 9. Preoperative view of tooth 37 damaged by caries.
The surfaces to be bonded were acid-etched and covered with a dentin enamel adhesive. A small amount of a photo-cured composite resin was placed on the fragment and placed into position against the coronal remnant. Polymerization was photo-activated for 3 to 4 minutes from all directions (Fig. 3).After bonding was completed a bevel was cut with a round diamond bur, half of it located in the remnant crown and half in the bonded fragment (Fig. 4). After the semicircular bevel had been cut, acid-etching (Fig. 5). bonding agent, and composite resin were placed like a belt all around the bonded joint. Finishing and polishing was performed at once, and the immediate postoperative appearance is shown in Figure 6.
REFERENCES Simonsen RJ.Traumatic fracture restoration:an alternative use of the acid etch technique. QuintessenceInt 1979; lO(2):15-22. Santos JFF,Vieira Rs,Pinto MFS. Posterior composite resin restorations with enamel inserts. Rev Odont USP 1989; 3:427-429. Santos JFF, Bianchi J. Restoration of severely damaged teeth with resin bonding systems: case reports. Quintessence Int 1991; 22(8):61 1-615. Santos JFF, Bianchi J. Restauration par collage de fragments de dents extraites. Clin Odontol 1991: 12(5): 339-343.
Cases 2 and 3 Another case treated using the technique described above is illustrated in Figures 7 and 8. The 4-year recall (Fig. 8) clearly illustrates #at a very satisfactory result was achieved by means of the bonded fragment restoration. In addition, Figures 9 and 10 show a different
3
Cases of serious coronal destruction were treated by bonding parts of extracted teeth to the coronal remnants by means of adhesives and photo-activated composite resins. The long-term clinical results have revealed very satisfactory clinical performance of the compounded restorations. No detrimental effects have been identified.
fter 6 years of research an innovative technique has been developed at the ClinicalResearch Center, Department of Dental Materials, University of SZio Paulo, utilizing the adhesive capabilities of new materials in combination with parts of extracted human teeth. Recently, improved adhesive materials have permitted the use of newly developed procedures for coronal restoration. A little more than a decade ago, Simonsen' described bonding fractured incisal edges to the remaining portion of crowns and emphasized two major advantages of such a practice: esthetics and wear resistance. At that time, bonding of dehydrated portions of teeth was not considered because of potential brittleness. In 1989 Santos and Cols2proposedreinforcement of posterior composite restoration with human enamel inserts. A series of well-documented cases have shown that such brittleness has not been clinically ~ b s e r v e d . It ~.~ seems that there is a critical period of 1 or 2 weeks after bonding, when rehydration of the bonded fragment is completed. In addition to the advantages mentioned by Simonsen' our experience has shown that bonding fragments of extracted teeth for coronal reconstruction has brought several more benefits such as (1) more conservative cavity preparation and less destruction of sound dental tissue, (2) a more natural esthetic result, (3)lower cost, and (4) more options for the d e n t i ~ t . ~ . ~ Representative cases of reconstructions by means of bonded fragments of extracted human teeth are presented to illustrate our new technique.
A
'Professor and Chairman:t Assistant Professor; Department of Dental Materials. Clinical Research Center. Untvemity of S o Paulo. Faculty of Odontology. S o Paulo. Brazil Address reprint requests to Professor Jose Fortunato Ferreira Santos. Clinical Research Center, University of S o Paulo. Faculty of Odontology. Av. Prof. Lineu Prestcs 2227. CEP 05508. S o Paulo. Brazil 0 1992 Decker Periodicals Inc.
MATERIALS Photo-activated composite resins associated with dentin and enamel adhesives, glass-ionomer cements, and parts of extracted human teeth were used for fabricating the restorations. The extracted teeth were thoroughly cleaned after the pulpal tissue had been removed through the apex, and stored in an antiseptic solution (70%ethanol). Just before bonding they were sterilized by humid heat (120" C) for 15 minutes.
TECHNIQUE Case 1 A young patient, 9 years old, had his left central incisor fractured in a swimming pool accident 4 days before coming to the office. At the initial appointment a clean-up was performed with a pumice/water slurry and an impression was taken (Fig. 1). A similar extracted tooth was selected and adjusted on the stone cast (Fig. 2).
Figure 1. Preoperative appearance of upper central left incisor, accidentally fractured.
1
JOURNAL OF ESTHETIC DENTISTRY VOLUME 4. SUPPLEMENT 1992
Figure 2. Fragment of an extracted similar tooth adjusted on the stone cast.
Figure 5. Acid etchingof the semicircularbevel all around the bonding line.
Figure 9. Bonding of the selected fragment to the coronal
Figure 6. Postoperative facial view.
remnant of tooth 2 1.
Figure 4. Semiclrcular bevel being cut with a round diamond bur.
Figure 7. Preoperative view of fractured tooth 2 1.
2
Biologic Esthetic Restorations
Figure 8. Checking interproximal contacts at the 4-year recall.
Figure 10. Appearance of tooth 37 at the 3-year recall.
situation where the entire occlusal table of a lower molar was restored with an adjusted tooth fragment, adhesive, and composite resin.
DISCUSSION Performance of the bonded restorations compoundedwith extracted human teeth, dentin and enamel adhesives, and composite resins have shown neither failures nor undesirable reactions during the 6-year recall period.3Conventional restorative dentistry might have been less effective due to its natural inherent limitations. Apart from the advantages already described, bonding human extracted teeth to coronal remnants offers better sealing and minimization of microleakage around the restoration, better long-term esthetic results, and more options for difficult clinical situations.
Figure 9. Preoperative view of tooth 37 damaged by caries.
The surfaces to be bonded were acid-etched and covered with a dentin enamel adhesive. A small amount of a photo-cured composite resin was placed on the fragment and placed into position against the coronal remnant. Polymerization was photo-activated for 3 to 4 minutes from all directions (Fig. 3).After bonding was completed a bevel was cut with a round diamond bur, half of it located in the remnant crown and half in the bonded fragment (Fig. 4). After the semicircular bevel had been cut, acid-etching (Fig. 5). bonding agent, and composite resin were placed like a belt all around the bonded joint. Finishing and polishing was performed at once, and the immediate postoperative appearance is shown in Figure 6.
REFERENCES Simonsen RJ.Traumatic fracture restoration:an alternative use of the acid etch technique. QuintessenceInt 1979; lO(2):15-22. Santos JFF,Vieira Rs,Pinto MFS. Posterior composite resin restorations with enamel inserts. Rev Odont USP 1989; 3:427-429. Santos JFF, Bianchi J. Restoration of severely damaged teeth with resin bonding systems: case reports. Quintessence Int 1991; 22(8):61 1-615. Santos JFF, Bianchi J. Restauration par collage de fragments de dents extraites. Clin Odontol 1991: 12(5): 339-343.
Cases 2 and 3 Another case treated using the technique described above is illustrated in Figures 7 and 8. The 4-year recall (Fig. 8) clearly illustrates #at a very satisfactory result was achieved by means of the bonded fragment restoration. In addition, Figures 9 and 10 show a different
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